Neuropsychol Rev (2007) 17:73–89
DOI 10.1007/s11065-006-9018-2
ORIGINAL PAPER
Psychosocial Treatments for Children with Attention
Deficit/Hyperactivity Disorder
Brian P. Daly · Torrey Creed · Melissa Xanthopoulos ·
Ronald T. Brown
Received: 30 November 2006 / Accepted: 30 November 2006 / Published online: 27 January 2007


C Springer Science+Business Media, LLC 2007
Abstract This article reviews studies examining the ef-
ficacy of behavioral interventions for the treatment of
attention-deficit/hyperactivity disorder (ADHD). A specific
emphasis is placed on evidence-based interventions that in-
clude parent training, classroom, academic, and peer interve-
ntions. Results indicate that school-aged children respond to
behavioral interventions when they are appropriately imple-
mented both at home and in the classroom setting. Combined
treatments (behavioral management and stimulant medica-
tion) represent the gold standard in ADHD treatment and are
often recommended as the first-line treatment option due to
the many problems faced by children with ADHD. Diversity
issues, although an important consideration in the treatment
of ADHD, continue to remain an understudied area. Rec-
ommendations for future research are made pertaining to
treatment sequencing with regard to behavior management
as well as for subgroups of ADHD children who may respond
best to specific treatments.
Keywords ADHD . Behavior therapy . Parent training
ADHD (attention-deficit/hyperactivity disorder) is a neu-
robehavioral disorder that may impede a child’s capacity to
sustain attention and effort, and to exercise age-appropriate
inhibition in behavioral settings or on cognitive tasks. The
syndrome is characterized by developmentally inappropriate
levels of symptoms that may include, but are not limited to,
inattention; failure to follow instructions; inability to orga-
nize oneself and school work; fidgeting with hands and feet;
talking too much; staying on task; leaving projects, chores,
B. P. Daly (
) · T. Creed · M. Xanthopoulos · R. T. Brown
Department of Public Health, Temple University,
3307 North Broad Street, Philadelphia, PA 19140, USA
e-mail: brian.daly@temple.edu
and homework unfinished; and having trouble paying at-
tention to and responding to details (American Psychiatric
Association [APA], 2000).
ADHD is the most commonly diagnosed behavioral dis-
order of childhood and is estimated to affect approximately
5% of the school-age children in the United States (American
Psychiatric Association, 2000), with a male to female ratio
ranging between 2:1 to 6:1 (Biederman, Lopez, Boellner, &
Chandler, 2002). Although the course of ADHD may vary
from individual to individual, research indicates that it is a
chronic disorder in which cognitive and behavioral mani-
festations typically emerge during the childhood years, and
consequently place children and adolescents at higher than
average risk for academic, behavioral, and social difficulties.
For example, despite some of the most intensive treatment ef-
forts for the disorder, most children with ADHD (over 80%)
still continue to evidence symptoms of the disorder at ado-
lescence (Barkley, Fisher, Edelbrock, & Smallish, 1990) and
even adulthood (Ingram, Hechtman, & Morgenstern, 1999).
This article will briefly review those limitations associated
with pharmacological management for ADHD in children.
Next, we examine the effectiveness of the most widely em-
ployed and accepted behavioral treatment approaches (parent
training, classroom interventions, academic interventions,
and peer interventions) for this population. A brief review
of the limitations associated with psychosocial treatments
also are examined. Findings from studies that have em-
ployed combined or multimodal treatment approaches are re-
viewed. Subsequently, we review the evidence for alternative
treatment approaches (metacognitive therapy, biofeedback,
and neurofeedback) for children with ADHD. We also dis-
cuss diversity issues as they pertain to employing psychoso-
cial treatments for children with ADHD and their families.
Finally, we make specific recommendations for future re-
search in this area.
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Pharmacotherapy
Stimulant medication in children and adolescents has been
the most widely investigated and frequently used class of psy-
chotropic agents in behavioral pediatrics and child and ado-
lescent psychiatry (Brown & Daly, in press). For example,
approximately 80% of children receiving pharmacotherapy
agents for the management of ADHD are prescribed stim-
ulants. The stimulants represent the class of psychotropic
medication most commonly prescribed for school-aged chil-
dren and adolescents, and are indicated for the manage-
ment of attention deficit/hyperactivity disorder (Jensen et al.,
1999; Teitelbaum et al., 2001; Zito et al., 2003). Research
has clearly demonstrated that stimulants are effective in the
management of those cognitive and behavioral symptoms as-
sociated with ADHD, which include inattention, impulsivity
and overactivity that occur in multiple settings such as the
classroom, at home, and in social settings involving peers
(Brown & Daly, in press). One of the primary criticisms
of stimulant drug therapy, however, is the lack of evidence
that stimulants produce either short- or long-term changes in
academic achievement. Moreover, there is not a compelling
literature to suggest that the stimulants improve the rather
guarded long-term prognosis of the disorder (MTA Cooper-
ative Group, 1999a; Weiss & Hechtman, 1993). Therefore,
given that many children and adolescents with learning or be-
havioral problems are frequently managed with stimulants,
it is important to be aware of both the safety and efficacy
of these agents (see Pliszka, 2006 in this issue) as well as
potential limitations regarding safety and efficacy.
Limitations—Physical
The most frequently reported adverse effects of stimulant
drug therapy are decreased appetite, headaches, abdominal
discomfort, problems falling asleep, irritability, motor tics,
nausea, fatigue, and social withdrawal (McMaster University
Evidence-Based Practice Center, 1999; Pliszka, 2000). Many
of the adverse side effects associated with stimulants in the
school-age population appear to be relatively mild, short-
lived, and linearly associated with dose (McMaster Uni-
versity Evidence-Based Practice Center, 1999). However,
there is some evidence to suggest that the adverse side ef-
fects of stimulants can be of sufficient magnitude to warrant
discontinuation of the medication. The most common man-
ifestations of adverse effects necessitating discontinuation
of medication include delayed sleep onset, reduced appetite,
stomachache, and headache (Santosh & Taylor, 2000), which
occur in 4–10% of children treated with stimulants. Further-
more, there are some reports to indicate that approximately
20–30% of children do not demonstrate significant bene-
fits from stimulant drug therapy (Pelham, 2000; Swanson,
McBurnett, Christian, & Wigal, 1995), although there is
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Neuropsychol Rev (2007) 17:73–89
some inconsistency with regard to these reports (for review
see, Brown & Daly, in press).
Academic achievement
Although stimulants improve short-term gains in academic
efficiency and productivity (Carlson, Pelham, Milich, &
Dixon, 1992; DuPaul & Rapport, 1993), the long-term effi-
cacy of stimulants on academic achievement has yet to be
demonstrated (Bennett, Brown, Craver, & Anderson, 1999;
Jadad et al., 1999; McCormick, 2003). Results from stud-
ies that evaluated the effects of stimulants on children with
specific learning disabilities failed to demonstrate any com-
pelling evidence to suggest that stimulants improved basic
learning disabilities (Alto & Frankenberger, 1994; Barkley
& Cunningham, 1978; Weber, Frankenberger, & Heilman,
1992). In addition, several studies suggested that there is
little or no improvement for children with reading disor-
ders who are treated with stimulant medication (Aman &
Werry, 1982; Ballinger, Varley, & Nolen, 1984; Cooter, 1988;
Gittelman, Klein, & Feingold, 1983).
Peer relationships
Stimulants often are associated with improved social func-
tioning, but they rarely normalize the behavior of ADHD
children to that of their typically-developing peers (Hoza
et al., 2005; Pfiffner, Calzada, & McBurnett, 2000). It also
is noteworthy that one study actually reported adverse ef-
fects on children’s social behavior following the initiation of
stimulant drug therapy. Specifically, in a placebo-controlled
trial of methylphenidate, children who received active med-
ication displayed muted social behavior, decreased social
engagement, and increased dysphoria relative to those re-
ceiving placebo doses (Buhrmester, Camparo, Christensen,
Gonzalez, & Hinshaw, 1992).
Family problems
Another limitation of stimulant treatment alone is that the
duration of action for most long-acting stimulant medica-
tions is eight hours (some agents may have longer duration),
thereby leaving a significant period of time during evening
or weekend hours in which caregivers must help children
manage their behavior. Parents often struggle in their efforts
to manage children’s impulsive, oppositional, and disruptive
behaviors that may occur in the afternoons and evenings,
weekends, and summers. Moreover, there is evidence to sug-
gest that some parents may choose not to medicate their
child due to adverse side effects or personal preferences.
Frequently, many caregivers report that psychosocial treat-
ments are more acceptable than medication (e.g., Reimers,
Wacker, Cooper, & De Raad, 1992). Although stimulant drug
Neuropsychol Rev (2007) 17:73–89
therapy remains the most prevalent treatment option for chil-
dren with ADHD, the clear limitations associated with medi-
cation management provide an important rationale to employ
evidence-based psychosocial treatment with these children
and their families either as an alternative or in combination
to medication.
Behavior management
Parent training
Symptoms of ADHD, such as inattention, hyperactivity, and
impulsivity not only affect a child’s daily functioning but
also may influence the functioning of the parent-child rela-
tionship, as well as increase stress in caregivers of children
with the disorder (Baldwin, Brown, & Milan, 1995; Wells
et al., 2006). Parental coping and parenting strategies may
become maladaptive and counterproductive in the attempt to
manage their child’s problematic behaviors, and may even
maintain or exacerbate the behavioral difficulties (Patterson,
DeBaryshe, & Ramsey, 1989). Therefore, family-based in-
terventions that focus on modifying antecedents and conse-
quences of their child’s behavior by parents are the focus of
behavioral parent training treatment for children with ADHD
(Pelham, Wheeler, & Chronis, 1998).
Behavioral parent training interventions are based on a
foundation of social learning principles that teach the child
more socially acceptable behavior by training primary care-
givers in contingency management strategies, emphasizing
behavior modification, cues, and consequences, reward sys-
tems, and discipline (Chronis, Chacko, Fabiano, Wymbs, &
Pelham, 2004). Parents learn how to identify and manipu-
late the antecedents and consequences of a child’s behav-
ior; target and monitor problematic behaviors; reward proso-
cial behavior through praise, positive attention, and tangible
rewards; and decrease unwanted behavior through planned
ignoring, time out, and other non-physical discipline tech-
niques (Chronis et al., 2001). In essence, these approaches
focus on reducing any positive reinforcement (e.g., parental
attention) being unintentionally provided to the child for en-
gaging in disruptive/defiant behavior, while simultaneously
increasing the reinforcement parents provide for appropriate
and compliant behavior. Punishment is contingent on the dis-
play of disruptive or unacceptable behavior, and parental use
of consequences is predictable, contingent, and immediate
to the behavior which precedes it (Barkley, 1997; Barkley,
2000).
Many studies have employed interventions that focus on
the above principles in 8 to 12 group or individual ses-
sions. A typical parent training program will include educa-
tional sessions on the child’s disorder, social learning theory,
and behavioral management techniques; training in specific
75
techniques for giving commands, reinforcing adaptive and
positive social behaviors of the child while ignoring minor
inappropriate behaviors to reduce or eliminate them; training
in techniques for establishing and enforcing rules and estab-
lishing time-out procedures; training on initiating a point sys-
tem with reward and response cost, and how to enforce con-
tingencies across settings; problem-solving techniques; and
strategies for maintenance and relapse prevention (Chronis,
Chacko et al., 2004; DeNisco, Tiago, & Kravitz, 2005). It
also has been emphasized that behavioral treatments must be
implemented consistently over the long-term, since ADHD
is recognized as a chronic condition (Chronis et al., 2001).
Behavioral parent training is one of the oldest and most
substantiated treatment interventions in child mental health
(Chronis, Chacko et al., 2004; Kazdin, 1997; Lundahl,
Risser, & Lovejoy, 2006), particularly for children with
aggression/conduct problems (Brestan & Eyberg, 1998).
Family-based interventions also have been effectively em-
ployed in children with ADHD for improving behavior in the
home setting (Huang, Chao, Tu, & Yang, 2003; Pelham et al.,
1998). In addition, the vast majority of children with conduct
problems or with a diagnosis of conduct disorder (CD) have
comorbid ADHD, and the effect sizes for parent training
are at least as large, if not larger, for comorbid ADHD/CD
children than for children with CD alone (Bor, Sanders, &
Markie-Dadds, 2002; Lundahl et al., 2006). Behavioral par-
ent training also has been found to increase parental knowl-
edge of ADHD and caregivers’ sense of competence in re-
sponding to their children, reduce parental and family stress
and improve maladaptive parenting behavior (Anastopoulos,
Shelton, DuPaul, & Guevremont, 1993; Chronis, Chacko
et al., 2004; Pisterman et al., 1992a; Weinberg, 1999; Wells
et al., 2000). For example, Weinberg (1999) examined 34
parents who participated in a 6-week parent training pro-
gram for 25 children ranging in age from 4 to 13 years who
also were being treated with stimulant medication (n = 23),
nortriptyline (n = 1), or guanfacine (n = 1). Results revealed
that parents who participated in the parent training program
reported significant improvement in their knowledge and
understanding of ADHD and behavior management skills,
and they also experienced slight reductions in the stress
of managing their child’s ADHD symptoms and behavior
problems. Furthermore, Sonuga-Barke, Daley, Thompson,
Laver-Bradbury, and Weeks (2001) compared two different
parent-based therapies and a wait-list control group for chil-
dren with ADHD in a community sample of three-year-olds
and their mothers. One parent-based group utilized parent
training, while the other group was a parent counseling and
support group. Results showed a statistically and clinically
significant effect of treatment on ADHD symptoms, as well
as significant effects on maternal adjustment and well-being
in the parent training group, but not for the other two groups
(Sonuga-Barke et al., 2001).
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However, there is a degree of variability in the effective-
ness of behavioral treatments in the management of ADHD
for individual children (Chronis et al., 2001; Chronis, Chacko
et al., 2004; Lundahl et al., 2006). The effects of behav-
ioral parent training are larger in specific domains, such
as compliance with parental requests, rule-following, de-
fiant/aggressive behavior, and parenting skills (Anastopou-
los et al., 1993; Pisterman et al., 1992b), than on specific
symptoms of ADHD as delineated by the DSM (MTA Co-
operative Group, 1999a; 2004). Furthermore, the literature
has revealed mixed results when examining the effectiveness
of behavioral parent training on improving child functioning
and reducing ADHD symptoms, which may be due, in part,
to methodological differences across studies (Lundahl et al.,
2006). For example, some studies obtained parent, teacher,
and child or adolescents ratings of child behavior (Barkley,
Guevremont, Anastopoulos, & Fletcher, 1992), while others
employed a blinded, objective rater of the child’s behavior
in the classroom (Wells et al., 2006). The studies that used
parental ratings as dependent measures have yielded sig-
nificant results; however, they may be influenced by rater
bias and expectancy effects given that the raters themselves
were involved in the treatments. In an attempt to address
this methodological problem, Wells and colleagues (2006)
designed a study that included baseline and post-treatment
laboratory observations of parent-child interactions which
were coded by trained observers that were blind to treat-
ment condition. Results revealed that multimodal treatment
(behavioral treatment in combination with medication man-
agement) resulted in significantly greater improvements in
parents’ use of proactive parenting strategies than did a
community-treated comparison group. It is noteworthy that
ratings for the medication management or behavioral man-
agement alone did not reveal improvements as had been re-
ported in a similar study that only employed parental ratings
(Wells et al., 2000).
The child’s age may also influence treatment outcome.
For example, younger children are dependent on parents for
fulfillment of basic needs and would therefore be expected to
be most responsive to behavioral management skills taught
in behavioral parent training programs (Kazdin & Weisz,
1998). Alternatively, adolescents are more advanced in their
abstract thinking and reasoning abilities, and are not as re-
liant on their caregivers to fulfill their needs. Therefore, they
may benefit from nonbehavioral programs that focus on im-
proving parent-child communication. However, there is no
consensus on how the child’s age influences parent training
outcomes (Serketich & Dumas, 1996). It has been suggested
that parent training may be fairly robust with regard to out-
come without any influence of age effects (Lundahl et al.,
2006).
Most studies of behavioral parent training and ADHD
have focused on children between 6 and 12 years of age,
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Neuropsychol Rev (2007) 17:73–89
but some studies have shown similar positive changes for
younger children (Bor et al., 2002; Pisterman et al., 1989;
Pisterman et al., 1992b; Sonuga-Barke et al., 2001) and ado-
lescents (Barkley, Edwards, Laneri, Fletcher, & Metevia,
2001; McCleary & Ridley, 1999). For example, Bor, Sanders,
and Markie-Dadds (2002) compared a standard behavioral
family intervention involving the education of parents on
child management strategies and an activities routine ap-
plicable to a broad range of target behaviors to an enhanced
behavioral family intervention that also included partner sup-
port and coping skills. Families (n = 87) of preschoolers with
disruptive behavior and attentional/hyperactivity difficulties
were assigned either to one of the intervention groups or to a
wait-list control group. Their results showed that both inter-
vention conditions were associated with positive outcomes
in child behavior problems, parenting skills and competence,
and parental conflict compared to the wait-list controls. How-
ever, the enhanced intervention program was not superior to
the standard program on any of these major outcome mea-
sures. Further, the results were maintained at a one-year
follow-up (Bor et al., 2002) attesting to the durability of the
intervention. Barkley and colleagues (1992), however, com-
pared behavior management training to problem-solving and
communication training, as well as to structural family ther-
apy in 12–18 year olds (n = 61) and their parents. Results
revealed that all three treatment approaches yielded signif-
icant improvements during conflict discussions in parent-
adolescent communication, number of conflicts, and anger
intensity at home as reported by the mother and adolescent.
In addition, all three treatments resulted in significant im-
provements in school adjustment as reported by parents, and
the dimensions of both internalizing and externalizing symp-
toms as reported by both parents and adolescents.
In a meta-analysis of parent training programs to modify
disruptive child behaviors, and parental behavior and per-
ceptions (Lundahl et al., 2006), findings indicated that par-
ent training designed to modify disruptive child behavior is
a robust intervention producing effect sizes in the moderate
range immediately following treatment. Although smaller
in magnitude, parent training effects remained durable at
one-year follow-up. In summary, a large evidence base ex-
ists for the use of parent behavioral interventions to reduce
ADHD symptoms, to improve parenting skills and their sense
of competence, and to diminish family distress. Given this
compelling body of literature attesting to its effectiveness,
behavioral parent training should be considered as a first-
line treatment for ADHD by itself or in conjunction with
medication.
Classroom interventions
Behavioral classroom interventions have been widely em-
ployed with children diagnosed with ADHD for more than
Neuropsychol Rev (2007) 17:73–89
three decades (e.g., O’Leary, Pelham, Rosenbaum, & Price,
1976), and even longer with children described as disruptive,
aggressive, or conduct-disordered at home or school (e.g.,
O’Leary & Becker, 1967). The results of these interventions
are consistent with established criteria for an empirically-
supported treatment (Pelham et al., 1998). Research sug-
gests that teachers widely implement behavioral classroom
interventions that target ADHD symptoms and associated
functional difficulties, such as complying with classroom
rules, engaging in appropriate interactions with classmates,
displaying disruptive behavior, and complying with teacher
commands. Reid, Maag, Vasa, and Wright (1994) found
that nearly three quarters of teachers surveyed reported the
use of behavioral interventions with students classified with
ADHD. In a recently completed survey, 81% of teachers re-
ported the use of behavioral modification techniques in the
classroom (Fabiano et al., 2001).
Direct contingency management strategies employed in
the classroom setting are more effective than traditional out-
patient treatment for ADHD-related behaviors (Pelham et al.,
1998). Classroom behavior management strategies are often
managed by means of consultation with the teacher and are
based on a functional analysis of the child’s problematic be-
havior. The consultant and teacher collaboratively develop
specific individual, classroom-wide, or school-wide behav-
ioral interventions such as verbal praise, effective commands,
a point or token economy system, daily report cards, or time
out (Chronis, Jones, & Raggi, 2006).
Relatively intensive behavioral programs typically were
studied in special classroom settings, whereas less intensive
programs often were examined in traditional classroom set-
tings. Intensive programs often included a token or point
system that may be implemented for an entire classroom
or school, rather than only for an individual child. O’Leary
and Drabman (1971) suggested that these behavior modifica-
tion systems, based on operant conditioning principles, have
three basic characteristics: (a) behaviors to be reinforced
are clearly stated (often in written format); (b) procedures
are designed for administering reinforcing stimuli (tokens
or points) when the target behavior occurs; and, (c) rules
are devised to govern the exchange of tokens for reinforc-
ing objects or events. Although children do not compete to
earn tokens, social reinforcement such as visible records of
achievement or verbal praise may increase the effectiveness
of the token system (Blackman & Silberman, 1980; Mercer
& Mercer, 1981). For example, Pelham, Burrows-MacLean
and colleagues (2005) demonstrated that an intensive, com-
prehensive behavior modification system with both reward
and cost components (e.g., token or point system, social
reinforcement, daily report cards, effective commands) pro-
duced a significant reduction in ADHD symptoms among
27 children, aged 6 to 12, in a classroom-based summer
treatment program. However, a combination of the behavior
77
modification system with stimulant medication (methyl-
phenidate) yielded a stronger treatment effect than either
treatments alone. These findings were consistent with pre-
vious empirical investigations of the efficacy of behavior-
modification in special classroom settings (Abramowitz,
Eckstrand, & O’Leary, 1992; Chronis, Fabiano et al., 2004;
Pelham et al., 1993).
Although more intensive programs in special education
classes tend to show a more salient effect, less intensive pro-
grams such as daily report cards or teacher consultation in
traditional classroom settings also demonstrate significant
effects (DuPaul & Eckert, 1997; Pelham et al., 1998). For
example, a daily report card for an individual child typically
contains 3 to 8 clearly defined positive behavioral goals, cho-
sen collaboratively by the teacher and parent. These goals
may target academic work, behavior, peer relationships, or
other areas of difficulty. The teacher monitors and records the
student’s success in meeting the behavioral goals, and pro-
vides feedback to the parent and child via the written daily
report card. When the child meets a predetermined level of
success, a reward is provided at home. The behavior required
to earn a reward is modified to require increasingly desirable
behavior as the child becomes better able to meet the spec-
ified behavioral goals (O’Leary et al., 1976). Employing a
daily report card was found to be consistently effective in
reducing core symptoms associated with ADHD for chil-
dren in traditional classroom settings (e.g., Chronis et al.,
2001; O’Leary & Pelham, 1978; Owens et al., 2005) and is
a commonly employed classroom intervention (Chafouleas,
Riley-Tillman, & Sassu, 2006).
The majority of the empirical evidence supporting be-
havioral classroom interventions has been based on single-
subject ABAB designs or group designs with a wait-list or no-
treatment control group. Treatment outcomes are frequently
measured by teacher and observer report (Barkley, 2002). In
a meta-analysis, DuPaul and Eckert (1997) found that be-
havioral classroom interventions showed a very large effect
size (ES = 1.44) on measures of treatment outcome, with a
larger effect on child behavior than academic or clinic per-
formance. These findings demonstrated strong support for
the efficacy of behavioral classroom interventions for chil-
dren with ADHD and associated symptoms. Given the high
frequency with which teachers report use of behavioral mod-
ification techniques in the classroom (Fabiano et al., 2001;
Reid et al., 1994), collaboration between behavior modifi-
cation specialists and teachers provides an excellent oppor-
tunity for empirically sound intervention for ADHD-related
behavior in the classroom.
Academic interventions
In contrast to classroom interventions that primarily fo-
cus on disruptive behavior and task engagement, academic
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interventions target the academic performance of children
with ADHD by focusing on the academic instruction, mate-
rials, or the environment (DuPaul & Eckert, 1998). Children
with ADHD frequently evidence difficulties in academic
achievement (Barkley, 1998; DuPaul & Stoner, 2003; Weiss
& Hechtman, 1993), high risk of comorbid learning disabil-
ities (Silver, 1992), and high rates of expulsion, dropout,
and grade retention (Barkley et al., 1990). For this reason,
emphasis on academic interventions is vital to the compre-
hensive treatment of ADHD. Preliminary evidence suggests
that a variety of interventions may enhance on-task behavior
in the classroom and, in some cases, academic achievement.
DuPaul, Ervin, Hook, & McGoey (1998) examined the
effects of peer tutoring on classroom conduct and academic
performance of children with ADHD (n = 18) and peer com-
parison students (n = 10) in traditional classroom settings.
Target children were paired with children perceived by the
classroom teacher to exhibit a high frequency of appropriate
behavior and to be on grade level in all academic subjects.
Students were observed while engaged in tasks related to
spelling or math, in an ABAB design. As a function of peer
tutoring, target children (both ADHD and peer comparison
students) demonstrated increased active engaged time and
decreased disruptive off-task behavior, as well as increased
scores on weekly academic tests. Of the children for whom
weekly subject test data were available, 50% of the children
with ADHD showed greater success with peer tutoring than
during baseline. It is noteworthy that children for whom the
intervention was effective were more likely to practice chal-
lenging material during peer tutoring. While these data are
consistent with other studies of peer tutoring (Greenwood,-
Maheady, & Carta, 1991; Locke & Fuchs, 1995), these data
would likely be strengthened by a larger sample design,
thereby providing greater statistical power, and a more ob-
jective means of choosing target and peer tutors.
Computer-assisted instruction (CAI) provides a highly
stimulating instruction format with frequent, immediate
feedback and reinforcement, and steady opportunities to ac-
tively respond to the instruction (Xu, Reid, & Steckelberg,
2002), all of which have been shown to improve the aca-
demic performance of children with ADHD (Barkley, 1998).
Although the literature examining the efficacy of computer-
assisted instruction is small, there is preliminary support
for the use of CAI in increasing academic achievement
across multiple areas of performance such as mathematics
(e.g., Mautone, DuPaul, & Jitendra, 2005), science (Shaw
& Lewis, 2005), oral reading fluency (Clarfield & Stoner,
2005), and attention and concentration (Navarro et al., 2003).
Methodological limitations such as small sample sizes and
limited follow-up data limit firm conclusions that might be
gleaned from these studies, but the findings to date sug-
gest that computer-assisted instruction may be a particularly
promising method of intervention.
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Neuropsychol Rev (2007) 17:73–89
Strategy training involves training children in procedures
to meet the requirements of a specific academic situation
(DuPaul & Eckert, 1998). Chase and Clement (1985) trained
six boys to self-monitor and self-reinforce in relation to a
daily academic or behavioral goal. Although strategy train-
ing was superior to medication alone, the combination of the
two interventions was the most efficacious. Strategy train-
ing that focuses on note-taking skills has demonstrated some
preliminary efficacy with adolescents (Evans, Pelham, &
Grudberg, 1995). Specifically, students who received strat-
egy training improved their note-taking skills (e.g., increased
detail, increased independence) and on-task behavior. In ad-
dition, students who took high-quality notes reduced their
disruptive behavior while increasing their comprehension
of material. Although these findings suggest that strategy
training may be potentially effective, small sample sizes,
non-traditional classroom settings, and other methodologi-
cal limitations do not yet support stronger conclusions and
generalization to other settings.
The goal of task and instructional modification involves
revising the curriculum in order to reduce undesirable class-
room behavior while promoting prosocial behaviors (DuPaul
& Eckert, 1998). Task and instructional modification may in-
volve changes such as shortening task length and increasing
opportunities for students to make choices between appropri-
ate alternatives (Dunlap et al., 1994), increasing specificity
or visual stimulation in instruction (Zentall, 1989; Zentall &
Leib, 1985), or allowing children to respond orally rather
than in written format (Dubey & O’Leary, 1975). How-
ever, empirical studies of task and instructional modification
also are typified by methodological limitations such as small
sample size, non-traditional classroom settings, and limited
follow-up data.
Peer related interventions
The literature has documented extensively that most children
with ADHD experience difficulties in developing and sus-
taining peer relationships (Milch & Landau, 1982; Nangle
& Erdley, 2001), and that impaired social functioning is con-
sidered one of the most debilitating aspects of their disor-
der (Greene, Biederman, Faraone, Sienna, & Garcia-Jetton,
1997; Greene et al., 1999). Specifically, children with ADHD
evidence a number of impairments in peer relationships due
to symptoms associated with their disorder, including hyper-
activity and impulsivity (e.g., annoying, bossy, immature,
boastful, intrusive, overbearing, and physically and verbally
aggressive behaviors) (Pelham, Fabiano, & Massetti, 2005).
Peers are often critical of the behavior of children with
ADHD because they consider these behaviors to be impolite
or offensive. In a recent investigation, Hoza and colleagues
(2005) examined peer ratings of children with ADHD rel-
ative to their same-sex typically developing counterparts.
Neuropsychol Rev (2007) 17:73–89
Findings indicate that peers rated children with ADHD as
lower on social preference, higher on social impact, less well
liked, and more often in the rejected social status category.
Children with ADHD had fewer dyadic friendships. Chil-
dren with ADHD tend to be more impulsive, argumentative,
and aggressive than their typically developing peers, and are
often rejected by their peers (Hodgens, Cole, & Boldizar,
2000; Hoza et al., 2005; Moser & Bober, 2002). It is note-
worthy that deficits in peer relationships and social function-
ing continue well into adolescence and even adulthood (e.g.,
Barkley, Fischer, Smallish, & Fletcher, 2004). In fact, poor
social relationships with peers are considered to be some
of the strongest predictors and mediators of negative adult
outcomes (Coie & Dodge, 1998; Huesmann, Lagerspetz, &
Eron, 1984), leading to maladjustment, mental health prob-
lems, criminal offenses, school dropout, and academic prob-
lems (for reviews see Parker, Rubin, Price, & Derosier, 1995;
Rubin, Bukowski, & Parker, 1998).
The finding that peer rejection of children with ADHD is
not only commonplace, but may lead to serious long-term
consequences, led to the design of psychosocial interven-
tions that specifically target peer relationships. Implement-
ing effective psychosocial interventions is important because
research demonstrates that children with ADHD who over-
come their social problems do better in the long term than
those children who continue to experience problems with
peers (Woodward & Fergusson, 2000). These interventions
include instruction in social skills, social problem-solving,
and behavioral competencies. In addition, the interventions
attempt to enhance social competence by encouraging close
friendships, and decreasing undesirable and antisocial be-
haviors. The psychosocial interventions remain especially
viable treatments for peer relationships particularly because
treatment with stimulant medication, while effective in re-
ducing negative social behavior, has not been proven to
increase positive behavior or normalize the peer status of
children diagnosed with ADHD (Landau & Moore, 1991;
Pfiffner et al., 2000; Whalen, Henker, Hinshaw, & Granger,
1989). Although children with ADHD are less socially ef-
fective than their peers, they do not perceive themselves as
such (Hoza et al., 2000). Thus, the primary goal of social
skills training is to promote prosocial behaviors that include
cooperation, communication, participation, and validation
(Kavale, Forness, & Walker, 1999). Social skills training rep-
resents the most common approach to treating social prob-
lems in children, with groups typically being conducted at
a clinic, summer treatment program, or in school-based set-
tings and often including parent and teacher participation.
Surprisingly, interventions that employ social skills training
as a stand-alone treatment for children with ADHD have not
demonstrated significant effects on the children’s social sta-
tus or on their overall social behavior (Kavale & Forness,
1996; Landau, Milich, & Diener, 1998; Pelham et al., 1988).
79
As one example, Antshel and Remer (2003) conducted a
randomized controlled trial that evaluated a social skills in-
tervention for children with either ADHD-Inattentive type or
ADHD-Combined Type. Although children who were ran-
domized to the social skills group demonstrated improve-
ments in both parent- and child-perceived assertion skills,
they did not evidence improvements across all other social
skills and domains of social competence, regardless of diag-
nostic subtype.
There is evidence that combining social skills interven-
tions with behavior management programs and parent train-
ing does improve ADHD children’s behavior toward their
peers (Frankel, Myatt, Cantwell, & Feinberg, 1997; Pelham,
1982; Pfiffner & McBurnett, 1997; Sheridan, Dee, Morgan,
McCormick, & Walker, 1996). One example of combining
intervention components is the Summer Treatment Program
developed by Pelham and colleagues (Pelham et al., 2005),
which is an intensive 8-week behavioral treatment interven-
tion for children with ADHD that includes social skills train-
ing, a reward and response cost system, group practice and
instruction in sports skills and team membership. Two well-
controlled crossover studies have demonstrated positive ef-
fects of the Summer Treatment Program and enhanced social
functioning of participants (Chronis, Fabiano, et al., 2004;
Pelham, Burrows-McLean, et al., 2005). Mrug, Hoza, and
Gerdes (2001) argue that in order to improve the effective-
ness of social skills interventions it is necessary to move
beyond solely focusing on improving the prosocial behavior
of children with ADHD by also targeting the peers’ cognition
and behavior toward the rejected child.
Houck, King, Tomlinson, Vrabel, and Wecks (2002) ex-
amined the effectiveness of group interventions with school-
age children with ADHD for enhancing social behavior. The
intervention employed group experiences that addressed four
domains of communication, friendship, self-control, and so-
cial problem-solving. All participants were being treated
with medication at the time of the intervention. Findings
indicated enhanced social behavior and decreased disruptive
behavior at the end of the group sessions.
Several investigators have argued that it is important to as-
sist children with ADHD to build and maintain close friend-
ships in order to improve their long-term social outcomes
(Bagwell, Schmidt, Newcomb, & Bukowski, 2001). Follow-
ing this premise, Hoza, Mrug, Pelham, Greiner, and Gnagy
(2003) designed a friendship intervention, which was imple-
mented within the context of an intensive behavioral treat-
ment program for children with ADHD. In the friendship
intervention, children were paired with a “buddy” based on
their preferences and other considerations. Special privileges
were accorded to the “buddy pairs” in order to increase the
frequency of their interactions and sharing. In addition, par-
ents were asked to organize play dates for their child and
his or her buddy in an environment outside the behavioral
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80
treatment program. Findings revealed that children paired
with less antisocial buddies demonstrated improved aca-
demic performance, were rated as having higher quality
friendships, and were viewed as more normalized. These ef-
fects also were found for children whose parents had higher
levels of compliance with the friendship intervention.
Strength of evidence for behavioral interventions
Objective, data-driven demonstration of the efficacy and
cost-effectiveness of psychological treatments needs to be
established in order to emphasize clinical psychology’s
strengths to the public, managed care, and other mental
health care professionals, (Chambless, 1996; Hunsley &
Johnston, 2000). The Task Force on the Promotion and Dis-
semination of Psychological Procedures (1995) developed
criteria and a classification system for evaluating the empiri-
cal support for various treatments. The criteria initially estab-
lished two categories of empirical support as either “well-
established” or “probably efficacious” (Chambless, 1996).
Two years later the criteria were updated such that evalua-
tion of the efficacy of a treatment required a treatment man-
ual for a specified population and targeted problem, reliable
and valid outcome measures, and appropriate data analy-
ses (Chambless & Hollon, 1998). Designation as a “well
established” treatment requires demonstration that the treat-
ment is: (1) statistically significantly superior to no treat-
ment, placebo, or alternative treatments; or, (2) equivalent to
a treatment already established in efficacy in a randomized
controlled trial, controlled single case experiment, or equiv-
alent time-series design. The superiority of this treatment
must be demonstrated in at least two independent research
settings. To merit designation as “probably efficacious,” one
study meeting the above criteria is sufficient if there is no
conflicting evidence. Additionally, each practice division of
the American Psychological Association (APA) established
a task force to examine the evidence concerning the efficacy
of psychosocial interventions (Lonigan, Elbert, & Johnson,
1998). According to the APA Division of the Society of Clin-
ical Child Psychology Task Force criteria, behavioral parent
training and behavioral school interventions are classified as
well-established empirically supported treatments. Although
preliminary evidence provides some support for academic
interventions, there is currently insufficient support for their
efficacy to earn an empirically-supported treatment classifi-
cation.
A large number of studies examined the efficacy of parent
training programs in treating ADHD, including randomized-
controlled trials using manualized interventions for children
and adolescents. In fact, several recent reviews and a meta-
analysis summarize this large body of literature (Chronis,
Chacko et al., 2004; Chronis et al., 2006; Lundahl et al.,
Springer
Neuropsychol Rev (2007) 17:73–89
2006; Pelham et al., 1998). Overall, it is concluded that
parent training results in improvements for children and their
families in several areas, such as parent ratings of problem
behavior, observed negative parent and child behaviors and
interactions, parental reports of stress, and parental reports of
increased knowledge and competence (Anastopoulos et al.,
1993; Chronis, Chacko et al., 2004; Pisterman et al., 1992a;
Sonuga-Barke et al., 2001; Weinberg, 1999; Wells et al.,
2000). Further investigations indicate that parent training for
disruptive child behavior is robust, with generally moderate
effect sizes reported (Chronis et al., 2006; Lundahl et al.,
2006).
Despite the large number of studies finding parent train-
ing to be an efficacious treatment, the results should be in-
terpreted with caution with regard to generalizability. As
discussed previously, there is a great deal of variability as
to which children improve with behavioral interventions,
likely the result of individualized and/or familial factors
(Chronis et al., 2006). Several mediators and moderators of
ADHD treatment effects are suggested, such as chronologi-
cal age, the presence of comorbidity, parental psychopathol-
ogy, parental cognitions regarding children and treatments,
socioeconomic status, race or ethnicity, family make-up and
social supports (Chronis, Chacko et al., 2004; Lundahl et al.,
2006). Further research examining treatment effectiveness
needs to be pursued in order to clarify the generalizability of
parent training for children and adolescents with ADHD.
School-based interventions also have been widely stud-
ied for children with ADHD. Behavioral interventions for
ADHD in the classroom were investigated in both single
subject (e.g., Abramowitz et al., 1992) and between-group
design (e.g., Gittelman et al., 1980) studies, commonly fo-
cusing on task engagement, disruptive behavior, and other
treatment outcomes as measured by direct behavioral ob-
servation, parent ratings, and teacher ratings. Behavioral
classroom interventions have shown very large effect sizes
on these measures (e.g., in the range of 1.44), with larger
effect sizes typically demonstrated on measures of class-
room performance (Chronis et al., 2006; DuPaul & Eckert,
1997).
In contrast to behavioral interventions, academic inter-
ventions in which the instruction or materials are modified
to improve behavioral or academic outcomes have garnered
preliminary support for their efficacy but have not yet met
the criteria for an empirically supported treatment. Peer tu-
toring (DuPaul et al., 1998; Greenwood et al., 1991; Locke
& Fuchs, 1995), computer assisted instruction (Clarfield &
Stoner, 2005; Mautone et al., 2005; Navarro et al., 2003;
Shaw & Lewis, 2005), strategy training (Chase & Clement,
1985; Evans et al., 1995), and task and instructional modifi-
cation (Dubey & O’Leary, 1975; Dunlap et al., 1994; Zentall,
1989; Zentall & Leib, 1985) each has shown preliminary
evidence of efficacy for increasing on-task behavior and,
Neuropsychol Rev (2007) 17:73–89
in some cases, achievement. However, firm conclusions
about the efficacy of academic interventions are prema-
ture, given the limitations in the literature. In addition, there
is a dearth of research using measures of treatment out-
come related to academic performance, including female
or adolescent participants, assessing generalizability over
time or setting, or evaluating treatment integrity (DuPaul &
Eckert, 1997). Systematic study of academic interventions
within a manual-based, randomized clinical trial with suffi-
cient power would greatly bolster confidence in the related
findings.
Limitations of behavioral treatments
The limitations associated with behavioral treatments for
ADHD are similar to those reported for stimulant drug ther-
apy. Specifically, employing behavior therapy as a single
treatment typically will not result in normalized behav-
ioral function for children with ADHD compared to their
typically developing peers. As with stimulant drug ther-
apy, most children will demonstrate psychosocial gains pri-
marily in the circumscribed period of time in which the
intervention is applied. That is, few studies (e.g., MTA
Cooperative Group, 1999) have demonstrated maintenance
of treatment gains following cessation of the behavioral in-
tervention. In addition, some children do not demonstrate
improvement following a course of behavior modification
(Pelham et al., 2000). It also is noteworthy that effect sizes
for acute stimulant medication effects tend to be higher for
the core symptoms of ADHD when compared to behavioral
treatments (e.g., Pelham et al., 1993). Finally, employing
behavior therapy may be difficult due to the need for contin-
ued intervention, the complexity of the therapy, dependence
on cooperation between parents and teachers, and the rel-
atively high cost of implementing behavioral interventions
(Barabasz & Barabasz, 2000) relative to pharmacological
interventions.
Combined interventions
As a result of the aforementioned limitations associated with
employing either stimulant therapy or behavior modification
as a stand-alone treatment, combined or multimodal inter-
ventions often are viewed as the gold standard for ADHD
treatment. However, depending on the treatment outcome
variable, some studies have not provided convincing data
to suggest the benefits of combined treatments of pharma-
cotherapy and psychotherapy relative to medication alone. A
study sponsored by the National Institute of Mental Health
(NIMH), entitled the “Multimodal Treatment Study of Chil-
dren with ADHD,” presents comprehensive data regarding
81
the efficacy of combined treatments for ADHD (MTA Coop-
erative Group, 1999a, 1999b). This study investigated lon-
gitudinal data on 579 children aged 7 to 10 years who were
diagnosed with ADHD, combined type, at six university
medical centers in the United States and Canada. The ef-
fects of four interventions were compared: (1) behavioral
intervention alone, including intensive treatment of parent
training and education, classroom behavioral management
training for teachers, social skills training, computer assisted
instruction, and a summer treatment program; (2) state-of-
the-art medication management; (3) a combination of med-
ication and behavioral intervention; and, (4) a control con-
dition of routine community care without an intervention.
This clinical trial showed that children in all 4 treatment
groups demonstrated reductions in core ADHD symptoms
over time. The combined treatment group and the medica-
tion management group alone were equally effective and
superior to the community control condition methods for ad-
dressing ADHD symptoms, with no additional benefit noted
for behavioral approaches alone or the typical community
care condition (MTA Cooperative Group, 1999a).
However, the MTA study demonstrated some measurable
benefits of multimodal psychosocial treatment component
over and above the medication management group (e.g., Pel-
ham et al., 2000). Specifically, the combined intervention
was most effective in mitigating related areas of functional
impairments including troubled family relationships, social
skills deficits, defiant and oppositional behavior, and poor
academic achievement (Hinshaw et al., 2000). Moreover,
these data indicated that combined treatment was superior
to medication alone for children with comorbid conditions
(e.g., anxiety disorder) and in the normalization of behavior
(Connors et al., 2001; Jensen et al., 2001; Swanson et al.,
2001). There also was evidence that the combined treatment
allowed for lower doses of stimulant medication and that
parents were most satisfied with the behavior and combined
treatment approach for management of their child’s ADHD
(MTA Cooperative Group, 1999a). Notably, the combined
treatment group continued to demonstrate superior effects
when compared to behavioral treatment alone at 10-month
follow-up, but only on symptoms associated with ADHD
and Oppositional Defiant Disorder.
The McMaster University Evidence-Based Practice
Center Group (1999) reviewed 20 studies to determine the
effectiveness of combined interventions versus single inter-
ventions. This review found that 19 of the 20 studies pro-
vided evidence that combined interventions were modestly
superior to non-pharmacologic intervention alone. How-
ever, other investigations of the effects of combined con-
tingency management training of parents or teachers along
with stimulant drug treatment were of little incremental bene-
fit over single-treatment approaches (Gadow, 1985; Pollard,
Ward, & Barkley, 1983). Another study found no additive
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82
effect for combinations of medication, child self-control,
and parent behavior management training (Ialongo et al.,
1993). In contrast, Horn and colleagues (1991) found that
gains were maintained on parents’ behavior ratings nine
months after the medication had been withdrawn for families
who had combined stimulant medication and parent training
treatments.
It was argued that to effectively increase prosocial behav-
iors in children with ADHD it may be necessary to combine
stimulant use with adjunctive psychosocial therapies, such
as social skills training or behavioral management (Bennett
et al., 1999). In fact, in a systematic review of the extant liter-
ature in this area, Jensen (2001) found combined treatments
that include stimulant medication and behavior therapy or
social skills training offer some modest advantages over sin-
gle treatment approaches. However, results from the MTA
study provided disparate results regarding the effectiveness
of combined treatment approaches on children’s social func-
tioning. Specifically, no advantage was demonstrated on any
measure of social functioning for the combined treatment
group over methylphenidate alone or methylphenidate plus
attention control. In an additional analysis of the MTA data,
children with ADHD were rated by their classmates on sev-
eral peer-assessed outcomes at the end of treatment. Results
revealed little evidence of the superiority of any of the treat-
ments for the peer-assessed outcomes studied, although the
limited evidence that did emerge favored treatments involv-
ing medication management (Hoza et al., 2005). Post-hoc
data analyses found that children from all four treatment
groups failed to achieve normal peer relationships and ac-
tually remained significantly impaired in their peer relation-
ships compared to randomly selected classmates (Hoza et al.,
2005).
Strength of evidence for combined interventions
Similar to behavior modification and stimulant medication
management approaches, combined or multimodal treat-
ments were shown to be evidence-based effective short-
term treatments for ADHD (Pelham & Waschbusch, 1999).
The MTA study results indicated that the effect sizes for
combined or multimodal interventions were nearly equiva-
lent when compared to stimulant treatment alone (moder-
ate to large) for their impact on the core ADHD symptoms
(MTA Cooperative Group, 1999a). However, it was argued
that combined treatment approaches produce stronger ef-
fects than stimulant treatment alone for specific functional
impairments such as conduct problems, oppositional behav-
ior, poor social skills, and disruptive behaviors (Connors
et al., 2001; Jensen et al., 2001; MTA Cooperative Group,
1999b; Pelham, Burrows-McLean, et al., 2005; Swanson
et al., 2001; Wells et al., 2000). Nonetheless, the evidence
Springer
Neuropsychol Rev (2007) 17:73–89
of the effectiveness of multimodal treatment in community
practice is limited (dosReis, Owens, Puccia, & Leaf, 2004).
Limitations of multimodal treatment
Evidence exists to suggest that a combination or multimodal
treatment is less cost-effective than medication management
alone for treating core ADHD symptoms (Jensen et al.,
2005). However, combined treatment approaches may be
more cost-effective for children with comorbid psychiatric
disorders (e.g., anxiety, depression) (Jensen et al., 2005).
Clearly, multimodal treatment is a time-intensive venture that
often necessitates the involvement of multiple professionals
in the care of children with ADHD and their families.
Alternative treatments
Among the alternative treatments suggested for ADHD
are electroencephalographic (EEG) biofeedback (neurofeed-
back or neurotherapy) and metacognitive therapy. EEG
biofeedback attempts to treat ADHD by increasing the ra-
tio of high-frequency ß-EEG activity to low-frequency θ -
EEG activity (Lubar, 1991). Despite some promising re-
sults, treatment effects may be due to nonspecific or placebo
effects (Barkley, 1992). A literature review by Lee (1991)
found biofeedback as a stand alone treatment program was
not effectively evaluated, and methodological problems of
the reviewed studies resulted in an inability to make gener-
alizations to populations with ADHD. Ramirez, Desantis,
and Opler (2001) also reviewed the literature on EEG
biofeedback as a treatment for ADHD and concluded that
methodological problems and a paucity of biofeedback re-
search precluded definitive conclusions regarding efficacy of
enhanced alpha and hemisphere-specific EEG biofeedback
training. Similarly, a National Institutes of Health (1998)
consensus report on ADHD treatment noted that the empiri-
cal evidence for treatments such as biofeedback was uneven
and recommended more controlled studies were necessary
before this treatment could be endorsed. Loo and Barkley
(2005) reviewed three treatment outcome studies applying
rigorous methodology that compared EEG biofeedback to
either no-treatment or placebo control conditions, and con-
cluded that two of the three studies failed to demonstrate
an active treatment effect. Their review led the investigators
to advise against the use of EEG biofeedback in a clinical
setting based on the current lack of supportive empirical data
(Loo & Barkley, 2005). Overall, despite anecdotal evidence
for these alternative treatments, reviews of the applicability
of neurofeedback for ADHD generally conclude that more
controlled clinical trials are needed before it can be endorsed
as an effective, reliable treatment.
Neuropsychol Rev (2007) 17:73–89
Diversity issues
Most research on children with ADHD has focused on
Caucasian males from middle-to upper-middle-class fami-
lies. Less attention was directed at females, children from
low socioeconomic backgrounds, or children from diverse
racial and ethnic backgrounds. For example, although there
is a significant increase in the documented prevalence of
ADHD among females (Hinshaw, Owens, Sami, & Fargeon,
2006), few investigations have addressed gender differences
in response to behavioral treatment. The literature indicates
comparable responsiveness to behavioral treatment and stim-
ulant medication across genders (MTA Cooperative Group,
1999b; Pelham, Walker, Sturges, & Hoza, 1989).
Socioeconomic status moderates behavioral treatment
outcomes for those with ADHD (Brown, Borden, Wynne,
& Clingerman, 1987; Firestone, 1982). Poorer behavioral
treatment outcome is associated with such socioeconomic
variables as single-parent status, low income, low education
(Dumas & Wahler, 1983; Knapp & Deluty, 1989; Webster-
Stratton, 1985; Webster-Stratton & Hammond, 1990), poor
adherence to treatment regimen, and higher attrition from
treatment programs (Biederman, Newcorn, & Sprich, 1991;
Firestone & Witt, 1982; Reid & Patterson, 1976). In addi-
tion, McMahon, Forehand, Griest, and Wells (1981) found
low socioeconomic status associated with low compliance
and poor outcomes following parent training for children
with behavioral problems. The MTA study found behav-
ior therapy resulted in some improvement over medication
alone on core ADHD symptoms for more highly educated
families (Rieppi et al., 2002). Although a majority of stud-
ies examining behavioral intervention effectiveness included
primarily Caucasian children, some investigations included
participants from various ethnic groups (Arnold et al., 2003;
Pelham et al., 1997; Reid, Webster-Stratton, & Beauchaine,
2002). Comparable improvement is reported for children
from various ethnic groups relative to their Caucasian peers.
Recommendations for future research
Behavioral treatment appears to be a short-term evidence-
based treatment modality applicable to children with ADHD.
Behavioral techniques are useful to improve ADHD symp-
toms and they may have a larger impact than stimulant medi-
cation on associated impairments, while stimulants may have
a larger impact on specific symptoms associated with ADHD.
The inherent limitations of behavioral approaches and phar-
macotherapy may be best addressed through a combination
of pharmacotherapy and behavioral treatment, and combi-
nation therapy has received widespread research attention
in recent years for ADHD and for other psychiatric disor-
ders, including depression and anxiety. In general, behavioral
83
approaches have no negative side effects. Although it was
suggested that the rewards integral to behavioral manage-
ment strategies may also have an iatrogenic effect and lessen
intrinsic motivation for many children (Akin-Little, Eckert,
Lovett, & Little, 2004), there have been no data for this po-
tential adverse effect. Because a combination of behavioral
treatment and stimulant medication have generally yielded
greater effects with the use of lower doses of stimulant med-
ication, the risk-benefit analysis of multimodal therapy is
considered more favorable than use of higher doses of stim-
ulant medication alone.
There is strong evidence that behavior management and
pharmacotherapy are each effective in the short-term, but
there are few investigations of the durability of these ap-
proaches and their safety over the long-term. Only one study
addressed the long-term use of behavioral treatment (MTA,
2004), and found that the acute benefits of behavioral treat-
ment may be sustained for a period of nearly two years.
However, there were no long-term studies (e.g., into adult-
hood) of behavioral approaches and such study remains an
important subject for future investigators.
Only one investigation has addressed the relative long-
term effects of stimulant medication, i.e., over a period of
two years. The MTA study data suggested that the beneficial
effects of stimulant medication dissipate upon discontinua-
tion of medication. Moreover, there was concern that growth
suppression may be an adverse effect of stimulant medi-
cation and a particular risk with long-term stimulant use.
For example, at the two-year follow-up of children receiv-
ing both stimulant medication and behavior therapy, these
children had a similar outcome to those receiving behavior
therapy alone, with the exception that the children in the
combined condition also evidenced growth suppression but
less than children in the medication only treatment arm. The
children in the combined arm were treated with lower doses
of stimulants. Thus, behavior therapy may make it possible
for lower doses of stimulant medication to be used with these
children (Pelham, Burrows-MacLean et al., 2006; Pelham,
Gnagy et al., 2006).
An important issue that remains to be addressed is the
sequence in which specific interventions should be imple-
mented in the management of ADHD (American Psycho-
logical Association, 2006). This is especially important in
clinical practice where the clinician is faced with the dilemma
as to whether medication or behavioral management should
be employed as a first line treatment, or whether the two
treatments should be implemented simultaneously. Related
questions include whether behavior therapy or stimulant
therapy should be employed first, how should the specific
components of treatment (e.g., parent training, school inter-
vention, peer intervention) be sequenced, and for how long
should behavior modification be implemented and at which
intensity prior to the initiation of medication? ADHD is a
Springer
84
chronic disorder that may require ongoing treatment, and a
determination needs to be made about whether and when
treatment may be terminated and whether specific compo-
nents of either behavioral management or stimulant med-
ication treatment may be time limited. The impact of de-
velopment on treatment considerations also requires further
clarification.
In addressing efficacy of behavior management and its
integration with medication treatment there also is a clear
need to assess systems of care within which the intervention
studies are evaluated (Stein, in press). Hinshaw (in press) ob-
served that careful investigations must address specific sub-
group effects, the mechanisms of action by which behavioral
therapies or stimulant medication may be effective, and the
important roles of mediators and moderators of outcomes of
these various treatment approaches. Racially- and culturally-
diverse families are generally underrepresented in clinical
trials of behavior management or the integration studies that
examine the efficacy of behavioral and medication treat-
ments, or their combination. There is increasing recognition
of the role of genetics as an etiology for ADHD, and it is
important to appreciate the influence of genetic predispo-
sition and its interaction with various treatment modalities,
including medication (e.g., pharmacogenetics) and behavior
management. Finally, a majority of studies focused on the
short-term outcomes of various behavioral approaches for
ADHD. Therefore, long-term outcome studies are needed
and given the duration of symptomatology over time, in-
vestigators must focus on improvement for the long-term
rather than simply short-term (Stein, in press). Important
gains were made in the identification and treatment of chil-
dren with ADHD over the past five decades. ADHD may
be the most meticulously researched disorder in the men-
tal health field. It is expected that important research will
continue and there will be even greater focus on treatment
options, combinations, and outcomes so as to improve the
quality of life for these children and their families.
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